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Step 1 of 4 - Patient Information

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NEW PATIENT INTAKE FORM

Patient Information
Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.
Patient Name*
First Last
Date of birth
YYYY slash MM slash DD
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Mobile Phone*
Email*
Who should we contact in case of emergency?*
First Last
Relationship*
Phone*
Do you have dental insurance?*
- Yes
- No
Primary Insurer
Insurance company name
Certificate/ID number
Group/Policy number
Are you a dependant?
- Yes
- No
Name of insurer
Insurer date of birth
YYYY slash MM slash DD
Relationship
Secondary insurer
Insurance company name
Certificate/ID number
Group/Policy number
Are you a dependant?
- Yes
- No
Name of insurer
Insurer date of birth
YYYY slash MM slash DD
Relationship
How did you hear about our clinic?*
- Internet search
- Social media
- Referral
- Newspaper or print ad
- Sign
- Other
Please specify:

NEW PATIENT INTAKE FORM

Medical history
Do you have a family physician?*
- Yes
- No
Name
Phone
Do you have a dentist?*
- Yes
- No
Name
Phone
Do you experience any dry mouth with or without medication?*
- Yes
- No
Have you ever had any head, facial, jaw, or neck trauma?*
- Yes
- No
Do any of the following conditions apply to you?
- Facial muscle tenderness
- Joint clicking, popping or locking
- Migraines or headaches
- Earaches
- TMJ (Jaw) pain
- Neck or shoulder pain
- Hearing issues
- Lumps or sores in your mouth now
- Grind your teeth
- Sore or tender gums
- Snore a lot
- Burning sensation on your lips or tongue
- Gasp or stop breathing in your sleep
Additional condition details:
Do you smoke?*
- Yes
- No
Are you allergic to the following?
- Latex
- Metal
- Acrylic
- Other
Please specify other allergy:
Have you ever had or are going through radiation or chemotherapy?*
- Yes
- No
When did you last go through radiation or chemotheraphy?
YYYY slash MM slash DD
Do you have hearing or memory issues where you may need extra assistance?*
- Yes
- No
Do you have any of the following serious illnesses?
- Heart condition
- High blood pressure
- Hepatitis A/B/C
- Drug addiction
- Cold sores
- Mouth cancer
- HIV or AIDS
- Epilepsy or seizures
- Tuberculosis
- Diabetes - Type 1
- Diabetes - Type 2
- Stroke
- Jaundice
- Asthma
- Sinus trouble
- Snoring
- Other
List other serious illnesses:
Is there anything else the denturists should know about your health?

NEW PATIENT INTAKE FORM

Denture History
Do you have a complete denture?*
- Upper denture
- Lower denture
- None
Upper denture: Age
Upper Denture: Last Reline
Lower denture: Age
Lower Denture: Last Reline
Do you have partial dentures?*
- Upper denture
- Lower denture
- None
Upper denture: Age
Lower denture: Age
Do you have implants?
- Yes
- No
Do you have any natural teeth remaining?*
- Upper
- Lower
- None
When was the last time you have seen a dentist?
Do you know if you need any dental work done?
ie. cleaning, fillings, extractions
- Yes
- No
- Not Sure
Please explain:
Are you happy with your current dentures?
- Yes
- No
- Somewhat
What are your concerns with your current dentures?
What is your goal with your dentures?

NEW PATIENT INTAKE FORM

Consent
Consent*
I, the undersigned, certify that all the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my Dentist, previous Denturist or Physician being contacted if necessary, as further dental/medical information may be required for my dental care. I, the undersigned, hereby consent to the performing of the preventative dental procedures. I, the undersigned, am aware that the whole amount of treatment is due to be paid by me and understand any direct billing to my insurance plan that comes back unpaid is to be paid promptly by me.*
Patient signature*
Email
This field is for validation purposes and should be left unchanged.

This is a preview of this form. No submissions will be received.

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